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EITI
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Early Intervention Training Institute
Rose F. Kennedy Center ■ University Affiliated Program
Winter 2000-2001
months of life! Because sucking is such a pleasurable
experience for infants, a significant number go on to
develop what is termed a “non-nutritive” sucking habit as
they grow into toddlerhood. The most common sucking
habits involve fingers and pacifiers. There is no evidence
that bottle-fed infants are more prone to develop a
sucking habit than those that are breast-fed.
ORAL HEALTH FOR INFANTS AND
YOUNG CHILDREN
A number of recent studies have revealed correlations
between oral health status and overall health. The
promotion of good oral health should begin before the
eruption of a child’s first tooth. The American Academy
of Pediatric Dentistry recommends that a child’s initial
dental visit occur at approximately six months after the
eruption of the first primary teeth. This is usually about
one year of age. Many children, however, do not visit the
dentist for the first time until a much later age. For this
reason, other individuals who have frequent interaction
with children, such as pediatricians, nurses and child
care workers, may have greater opportunity to direct
early preventive dental care and detect pathology.
The effects of the sucking habit on the dentition vary
widely from child to child. They are dependent on
frequency, intensity and duration of the habit. Many
children will, on their own, discontinue a sucking habit by
three to four years. In most cases, a habit that stops at
that point will have little to no residual effect on the
permanent dentition. Although pacifier sucking affects
the dentition in much the same way as finger sucking, it
is probably an easier habit to discontinue. This is simply
because a pacifier can be taken away from a child; fingers
can’t!
Development of the Dentition
The primary teeth start to develop at approximately 5-6
weeks in utero. Adequate intake of calcium, phosphorus
and vitamins A, C and D by the expectant mother will
help to ensure proper formation of the unborn infant’s
teeth. Although the first permanent teeth do not erupt
until around six years of age, the enamel of these teeth
starts to form at or around birth. Parents should be
aware that certain medications (the most well-known one
being tetracycline), if taken during the first few years of
life, might permanently discolor the developing enamel of
the permanent teeth. Also, early childhood illnesses that
result in prolonged high fevers or poor nutrient
absorption can disrupt the proper formation of the teeth.
If a child continues to suck his/her fingers as the
permanent teeth erupt, it may result in a “malocclusion”
or poor alignment of the teeth. An older child may require
the assistance of parents and/or the dentist to
discontinue the habit. A number of different methods
exist and each family must explore what will be successful
with their child. The most important factor in
successfully stopping a finger habit is the child’s
understanding of the need to stop and his/her desire to
do so.
Tongue thrusting, which is characteristic of infantile
swallowing, is another behavior that may persist to an
older age. A persistent tongue thrust may prevent the
normal eruption of the front teeth (incisors), and be
related to a type of malocclusion called an anterior open
bite, in which the upper and lower incisors do not come
together in the proper way. As with sucking habits, the
extinction of a tongue thrust may require the assistance of
parents, the dentist and possibly the speech therapist.
Mothers-to-be should be careful not to neglect their
own oral hygiene during pregnancy. In addition to
reducing the incidence of gingivitis and tooth decay in
their own mouths, optimal oral hygiene, which reduces
oral bacterial counts, can help reduce the incidence of
dental disease in their children.
Teething
The average age for eruption of the first primary teeth
is six months. There is, however, wide variability, and
some children may be as old as one year before the first
teeth appear. All twenty primary teeth have usually
erupted by three years of age.
Bruxism, or tooth grinding, is reported in a significant
number of preschool children. The etiology of bruxism in
this age group is not clear, and it has not been linked
conclusively with any illnesses. Although bruxism
produces a sound that can be very annoying to parents
and caregivers, it is, in most cases, not harmful to the
primary dentition. The majority of children will
spontaneously stop tooth grinding as the permanent teeth
erupt. Some older children may revert to the habit during
times of stress. This can lead to soreness of the jaw
muscles and, if persistent enough, cause excessive wear
and loosening of the teeth. Although a night guard (or
“bite guard”) may be useful in helping some older children
break a grinding habit, it is important to determine
sources of stress that may be occurring in the child’s life
and to address those issues. Some children with
developmental disabilities may continue to grind their
teeth. This can be an extremely difficult habit to break in
a child who is resistant to wearing a bite guard and may
be engaging in it as a form of self-stimulation.
Parents sometimes attribute a wide range of physical
symptoms in their infants to teething. However, a great
deal of disagreement exists in the medical and dental
communities as to whether a true relationship can be
found between tooth eruption and these disturbances.
Symptoms attributed to teething include increased
drooling, irritability, gastrointestinal (GI) upset, lack of
appetite and fever. Any young child with fever, prolonged
GI problems or loss of appetite should be evaluated by a
physician to rule out causes other than teething. It
should never be assumed that these symptoms are
secondary to tooth eruption.
Oral Habits
The sucking reflex is natural and necessary for infants;
it is the only means of obtaining nutrition in the first few
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Dental Caries
during pregnancy. They should be informed that, in most
cases, routine dental visits during pregnancy are not
contraindicated.
Although dental caries (tooth decay) is still thought by
many to be simply an inevitable result of consuming
excess “sweets”, it is, in fact, a preventable, infectious
bacterial disease. Several components are needed for the
decay process to advance. First, and most obviously,
there must be teeth! Second, the specific bacteria
responsible for dental decay must be present in the
mouth. Third, the bacteria require a source of
fermentable carbohydrates (sugar in any form). The
bacteria will manufacture acid as a byproduct of
digesting the carbohydrates, and it is this acid that
actually causes the destruction of tooth structure. Other
factors, such as frequency of eating and salivary
composition (which may be genetically determined), also
contribute to caries levels in children’s mouths.
Once the child is born, it is a good idea to establish
regular oral hygiene habits, even before teeth erupt. The
baby’s gums should be wiped gently with a moist gauze or
washcloth after each feeding. This routine should
continue as the primary teeth erupt.
Children can start using a brush by about age two. A
child should never be allowed to apply toothpaste to the
brush or to brush their teeth without supervision at the
toddler and preschool ages. Parents should be instructed
to place only a small, pea-sized amount of toothpaste on
the child’s brush. They should be aware that, although
“children’s toothpastes” may have milder flavors than their
adult counterparts, they do contain fluoride. Excessive
ingestion of fluoride at this age can cause later problems
with staining of the permanent teeth, whose enamel is
forming throughout early childhood. By about age six,
many children are capable of brushing on their own.
Parents, however, should continue to monitor the mouth
for good hygiene.
A number of studies have shown that the bacterial
group “mutans streptococci” (ms) is strongly associated
with dental caries. The mouths of newborn infants do
not harbor this particular organism. It seems that teeth
must be present to provide a surface suitable for ms
colonization. If the bacteria are not present at birth, how
exactly does the young child acquire it? Several studies
have shown that children infected with ms display the
same bacterial strain of ms that is present in the mouths
of their mothers or primary caregivers. A critical level of
ms must be present for dental decay to proceed. One
study found that children with less than 10,000 units of
ms/ml. of saliva were generally caries-free. Most
children with extensive oral colonization by ms are
probably infected sometime between the ages of one and
two years. The transmission from mother to child can
occur in any number of ways: kissing, sharing eating
utensils, an infant putting his hand into mom’s mouth
and then into his own.
The incidence of dental decay increases with greater
duration and frequency of carbohydrate ingestion. Milk,
juice or other sweetened beverages should only be given at
specific meal or snack times. Small children should not
be allowed to walk around drinking from a bottle or “sippy
cup” throughout the day, unless it is filled with plain
water. A nighttime bottle containing anything other than
water should also be discouraged as early as possible.
Fluoride supplementation has been proven over a period
of many years to be effective in dental caries prevention.
Fluoride works topically by remineralizing areas of tooth
enamel that may have become decalcified by bacterial
acid. People who live within New York City should be
aware that the NYC municipal water supply is
supplemented with optimal levels of fluoride and no
additional supplementation is required on a routine basis.
Many families today, however, utilize bottled waters for
most of their drinking and cooking needs. The amount of
fluoride in bottled waters varies widely between different
brands. Parents should be aware of the amount of
fluoride in the bottled waters they are using and discuss
with their child’s primary health professional the need for
any additional supplementation. People residing in
municipalities outside of NYC proper should know that
fluoride varies on a town-by-town basis. They should be
aware of the amount of fluoride in their towns’ water
supplies and, again, discuss the need for additional
fluoride with a health care provider.
Early Childhood Caries (ECC), formerly termed
“nursing bottle” or “baby bottle” decay is a particularly
rampant form of dental decay seen in young children.
While extensive and prolonged bottle-feeding may be a
contributing factor to dental caries in this age group, it
was felt that the name should be changed to ECC to
reflect the growing recognition of the multifactorial
nature of the dental caries process.
ECC typically affects the upper incisors (front teeth)
first and, if left untreated, may spread throughout the
dentition. The process often starts on the palatal (back)
surface of the incisors and can easily go unrecognized
until the teeth become so extensively decayed that they
have large, unsightly holes or actually break. With the
presence of enough bacteria and carbohydrates in the
child’s mouth, the breakdown of the teeth can be quite
rapid.
In conclusion, optimal oral health for a child starts
before birth, with the mother-to-be taking care of her own
oral needs. Dental caries is a multifactorial disease
process that can be prevented through a combination of
good daily hygiene and dietary practices. Pediatricians,
nurse practitioners, child care workers and any other
individuals who are involved with small children on a daily
basis can contribute to a child’s oral health by helping
them to establish good habits at an early age. Regularly
scheduled preventive dental visits started at an early age
will help to alleviate some of the anxiety associated with
going to the dentist. A healthy smile is a gift that lasts a
lifetime.
Prevention of Dental Caries
Ideally, the prevention of dental caries should start in
the pre-natal period. As discussed earlier, dental caries
is a transmissible disease. Although it is virtually
impossible to completely stop the transmission of oral
bacteria from mother to child, reducing the bacterial
count in the mother’s mouth can minimize it. Mothersto-be should be counseled to maintain good oral hygiene
Nancy Dougherty, DMD
Director, CERC Dental Unit
Edited by S. Vig and R. Kaminer Copyright © 2001
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